Total Abdominal Colectomy
What the Examiner Expects
Removal of the entire colon from the cecum to the rectosigmoid junction, preserving the rectum. This differs from total proctocolectomy, which also removes the rectum. The examiner expects you to know the specific indications: fulminant C. difficile colitis unresponsive to medical therapy, toxic megacolon in ulcerative colitis, synchronous colon cancers, FAP (if rectum can be surveilled), and massive lower GI bleeding where the source cannot be localized despite endoscopy and angiography. In emergency settings (fulminant colitis, massive hemorrhage), an end ileostomy with Hartmann's closure of the rectal stump is the safest approach.
Key Examiner Focus Points
- Indications: synchronous cancers, FAP, fulminant C. difficile colitis, toxic megacolon in UC, massive lower GI bleed with no identified source
- Resect cecum to rectosigmoid junction; ileorectal anastomosis if rectum is spared
- End ileostomy if anastomosis is unsafe (sepsis, unprepared bowel, hemodynamic instability)
- For FAP: total proctocolectomy with IPAA is preferred if rectum also has polyps
- 3–5 liquid bowel movements per day expected after ileorectal anastomosis
Common Curveballs
Patient with fulminant C. difficile and WBC > 30,000 — you're called to evaluate for surgery
Operative indications for C. difficile: WBC > 15,000, lactate > 5, organ failure, peritonitis, toxic megacolon, perforation. Perform subtotal colectomy with end ileostomy. An alternative emerging approach is diverting loop ileostomy with colonic lavage (vancomycin flushes), but subtotal colectomy remains standard for fulminant disease.
Massive lower GI bleed — colonoscopy, tagged RBC scan, and angiography all fail to localize the source
If the patient requires ongoing transfusion (> 6 units) and the source cannot be localized, a total abdominal colectomy with ileorectal anastomosis (or end ileostomy if unstable) is indicated. A segmental colectomy without localization has an unacceptably high rebleeding rate.
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